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SERVICE REQUEST ``.W (SERVREO) Revised 8/23/93 <br />FACILITY NAME 4G'Lt.YLA�_� <br />SITE ADDRESS �13. J6L�I _�c.lwt,.c— /— �j /� j�'7 <br />CITY �Q�.�'Q"VT CA ZIP -`7 Z)C o- <br />0WHFR/OPERATOR BILLING PARTY -Y / N <br />DBA PHONE #1 ( -)�Q- <br />ADDRESS \ ^PHONNEE #2 ( f t ) r t - t L <br />CITY tCC� ` STATE �� ZIP �J („)✓C� <br />MN #-- I [ Land Use Application # <br />I— — BOS Dist Location Code <br />CONIRACTOR and/or rr7y�' <br />SERVICE REOUESTOR A�y!/�f ��Z I/�y�'LG� 13ILLING PARTY T <br />Y / <br />DBA r� ''"' ) PHONE #1 ( ) <br />MAILING ADDRESS JD b lV ji� �,.t/� FAX # <br />CITY- A-tr)/ STATE ZIP 14ar/V <br />a <br />PILLING ACKNOWLEDGEMENT: 1, the Undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br />PHS/END hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br />Page 1 of this form. <br />1 also certify that I have <br />prepared this application and that the work <br />to be performed will be done <br />in <br />all SAN <br />JOAQUIN COUNTY Ordinance Codes <br />and St.nda rds tete and erat taws. <br />�cfgr,�((g�"th <br />..__... _..... ___-- <br />RPACTT EMM����1IPVD <br />IqQ <br />APPLICANT'S SIGNATURE <br />Al <br />y � I'll"! <br />3 1996 <br />Title: _ Date: 1p SAN,;uAOUINCUuivey <br />—� RO IL;�Ap�� EnnA��LT.HnSERVICES <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, oper'HteffTbT� kljAlTdf ®I<�I� <br />the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br />environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br />it is available and at the same time it is provided to me or my representative. <br />Nature of Service Request: Service Code _ f_ �L <br />ASsigned to 1C Employee # '� �3_ Date <br />Dale Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Reevd By <br />..__... _..... ___-- <br />IqQ <br />OFIIS SUPV I =_ /_ _ / I ACCT h �_//_�._ I UNIT CLK <br />